Provider Demographics
NPI:1952561649
Name:PETITH-PAULSEN, JOAN M (PA)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:PETITH-PAULSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 STATE HIGHWAY 30
Mailing Address - Street 2:KEM PLAZA
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7418
Mailing Address - Country:US
Mailing Address - Phone:518-842-0285
Mailing Address - Fax:
Practice Address - Street 1:4803 STATE HIGHWAY 30
Practice Address - Street 2:KEM PLAZA
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7418
Practice Address - Country:US
Practice Address - Phone:518-842-0285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001757OtherLICENSE